A STUDY ON MANAGEMENT OF RURAL HEALTHCARE IN ANDRA PRADESH

NENAVATH SREENU Ph.D SCHOLAR

SCHOOL OF MANAGMENET, UNIVERSITY OF HYDERABAD.

Literature review

Rygh EM, Hjortdahl P (2007) this article examined possible ways to improve healthcare services in rural areas. While there is abundant literature on making healthcare programs integrated, interdisciplinary and managed in order to reduce fragmentation and improve continuity and coordination of care, only some part of this relates to rural issues. An added challenge is the lack of a generally accepted international definition of rurality, which makes it difficult to generalise from one region to another, and to develop an evidence-based understanding of rural health care. In evaluating the literature it was found that the development of new forms of interaction is particularly relevant in rural regions - such as interdisciplinary and team-based work with flexibility of roles and responsibilities, delegation of tasks and cultural adjustments. In addition, programs such as integrated and managed care pathways, outreach programs, shared care and telemedicine were relevant initiatives. These may be associated with greater equity in access to care, and more coherent services with greater continuity, but they are not necessarily linked to reduced costs; they may, in some cases, entail additional expenses. Such endeavours are to a large degree, dependent on a well functioning primary healthcare system as a base.Haines; R. Horton; Z. Bhutta(2007) This article reviewed the vision of primary health care (PHC) in the Alma Ata declaration and highlights some of the management concept between this and the selective approach to PHC, which promotes a few cost-effective interventions. The author’s explain that despite movements towards selective packages of care and health-care reforms the idea of PHC as described in the Alma Ata declaration is attracting renewed interest. There are several reasons for this shortages in health workers, especially in developing country or states, have renewed interest in the role of community-health workers; the study also highlights the growing research evidence about the cost-effectiveness of some components of PHC, such as the role of community participation improving neonatal and maternal mortality in India. PHC is also better able to address pervasive health inequalities, poor coverage of basic health care, and lack of engagement by communities in health systems.

WHO Report (2008) World Health Organization review examines the implementation of primary health care (PHC) in Africa and identifies strategic interventions those are

1

required to cope with the new challenges facing the health systems in the 21st century. The review addresses PHC policy formation and implementation, the resources that are available for PHC implementation, monitoring and review. The review finds that PHC policy formation had been well articulated in the national health policies by most countries, however, the extent to which PHC policies encompassed equity, community participation, inter-sectoral collaboration and affordability is still questionable. Factors delaying PHC implementation include weak structures, inadequate attention to PHC principles, inadequate resource allocation and inadequate political will. The recommendations of the review include to: 1). health sector reforms with PHC to ensure that initiatives promote equity and quality in health services 2). Improve the fairness of financing policies and strategies and service coverage for the poor 3). Support countries to address their particular human resource needs through clear articulation of human resources policies, plans, development and strengthening of national management systems and employment policies 4). Support countries to identify and put in place mechanisms for attracting and retaining health personnel J. Macinko; H. Montenegro; C. Nebot (2007) this document states the position of the Pan American Health Organization on the proposed renewal of primary health care (PHC) in the Americas. It highlights reasons for adopting this renewed approach. These include: the rise of new epidemiologic challenges that PHC must evolve to address and the growing recognition that PHC can strengthen society’s ability to reduce inequities in health. The document examines the concepts and components of PHC and the evidence of its impact. It finds that PHC represents a source of inspiration and hope for most health personnel and also the community at large. There is a need to reinvigorate PHC in the region so that it can realise its potential to meet current and future health challenges. The proposed mechanism for PHC renewal is the transformation of health systems so that they incorporate PHC as their basis. This system entails an overarching approach to the organisation and operation of health systems that makes the right to the highest attainable level of health its main goal. The health system should be composed of a core set of functional and structural elements that guarantee universal coverage and are equity enhancing. This requires a sound legal, institutional, and organisational foundation as well as adequate and sustainable human, financial and technological resources.D. McCoy; E. Buch; N. Palmer (2000) The devolution of primary health care delivery to local government means that intergovernmental relations are emerging as a critical issue in the transformation of South Africa’s health system. The role of contracts or service agreements in helping to define the nature of these inter-governmental relationships is important and complex. This document, produced by the Health Systems Trust, considers the nature of inter-governmental relationships, the type of contract most likely to be appropriate in helping to define and control them, as well as some of the

2

potential pitfalls of an 'overly zealous' approach to contracting for a service such as primary health care (PHC). More specifically, this study introduces the advantages and disadvantages of contractual relationships within the public health sector, examines different types of contracts, describes the nature of inter-governmental relationships in South Africa and features of the PHC Approach and District Health System model integral to the South African health system, and discusses how these factors will influence and potentially be influenced by the use of contracts. It also emphasises the importance of integrated district and provincial health planning as the basis for contracts. In addition, this study discusses the issues raised and draws conclusions of interest to those involved in the process of establishing contracts. This study makes the following recommendations for a successful inter-governmental contractual relationship for the provision of PHC: 1. Work from a national / provincial strategic and policy framework, and from a comprehensive and integrated area-based PHC plan. 2. Adopt a relational approach to contracting that encourages partnership, and emphasises trust, mutual support and a shared vision. 3. Adopt contract specifications that are broad and flexible, and which stress constructive monitoring and evaluation procedures. According to Pual (2008) Health Policy and Development, compares the attrition rates of health professionals in three private not-for-profit and three government general hospitals in West Nile Region, Uganda, between 1999 and 2004. It also examines the destination to which the rural healthcare professionals were lost, the reasons for their leaving and the source of new staff. The article finds that the annual attrition rate of health professionals are high especially in private hospitals. The most frequent reasons for attrition are poor conditions of service, low pay and poor relationships between the staff and the managers. Most replacements come from training institutions, which impacts on the quality of services in terms of the skills needed for service delivery the authore offers recommendations to the Ministry of rural Healthcare. These include to:1. Offer well managed additional monetary incentives to health workers service in the rural areas 2. Put more funds into the health sector in order to fill in staffing gaps 3. Invest funds in training of health service managers for better management of health service. Healthcare system 2020 Report (2008) the study identifies healthcare issues and challenges and reviews some experience with interventions to improve health delivery. Interventions aimed to: improve the policy process in the health sector by promoting more effective stakeholder engagement, enhancing participation at a variety of levels to promote more effective delivery of health programmes, and improving accountability and transparency in the health sector. The article concludes that good healthcare delivery emerges from the actions and linkages among the state, providers of healthcare services and citizens. Healthcare delivery improvements through their impacts on rules, roles,

3

responsibilities and institutions – affect the availability, quality, distribution and utilisation of health services. Efforts to increase the quality of healthcare governance constitute worthwhile and effective undertakings for improving health systems functioning and for increasing the provision and utilisation of health servicesKaveri gill (2009) the study seeks to evaluate quantity and quality of service delivery in rural public health facilities under NRHM. On appropriate and feasible measures, the former is assessed on the static and dynamic condition of physical infrastructure; by the numbers of paramedical, technician and medical staff employed, The micro-findings across four states (A.P, UP, Bihar, Rajasthan), which have resulted in rankings in individual sections of the study, suggest disparate situations at various levels of centres and on different components, reflecting context-specific underlying driving factors, some complex by nature. Based on these findings, one could easily rank the states on ‘overall performance of service delivery under NRHM’, but to do so would be irresponsible, meaningless and defeat the very purpose of this evaluation, which was to highlight the micro-components of features that are important to this Mission’s capacity to deliver services, The NRHM has put rural public health care firmly on the agenda, and is on the right track with the institutional changes it has wrought within the health system. True, there are problems in implementation, so that delivery is far from what it ought to be. On physical infrastructure, medicines and funding, processual problems might be more easily scaled with time (in some instances, they already appear to have been overcome), whereas on human resources, and to the extent these impact actual availability of services,T. V. Sekher (2002) This article explain The delivery of rural healthcare services in India remains poor, particularly in rural areas, due to lack of infrastructure and personnel, financial constraints, lack of awareness, poor accountability and transparency. Though the networks of the department have spread to almost every village, the availability and utilization of the services continue to be very poor and grossly inadequate. In this situation, cans the panchaythi raj institution (PRIs) make a difference in the delivery of rural healthcare services The philosophy behind bringing the line departments, including health, responsible for providing essential services, under the supervision of local elected bodies is to achieve an overall improvement in the delivery of services at the grass roots level. This can be facilitated through the interventions of PRIs by making health services responsive to local needs, more accountable to the local population, focusing on local problems, prioritizing the requirements, generating public demand for the services and efficient use of available resources. The study attempts to explore these issues in the context of karnatak in India, a state which is considered to be the pioneer in devolving powers to grass roots level elected bodies. Methodology of this reviewed a study of this nature and magnitude demands not only information and inputs from macro levels but also insights from grass roots level. Therefore, to begin with, discussions were carried out with health functionaries at all levels, the community health centers (CHCs), primary health centers (PHCs) and sub-centres were visited and their functioning examined. It is

4

useful to examine the financial implications of the national rural healthcare mission in the context of the deteriorating trend in public health spending in India. A.P govt health report (2008) Government of Andhra Pradesh has launched the national rural healthcare mission (NRHM) in April 2005. While Andhra Pradesh needs to spend an additional Rs. 17 Billion to scale up the rural primary healthcare services, but not providing quality healthcare due to lack of allocation of funding as well as implementation of management problems. On a per capita expenditure basis, kerala is first ranking and Punjab with high expenditure and good healthcare indices and lowest ranking is Bihar. The Andhra Pradesh ranking is 12. Continue to have poor healthcare indices in spite of relatively higher expenditure while funds are no doubt, needed to improve healthcare and healthcare indices awareness, equitable distribution and utilization of services is equally critical for the improvement of healthcare indices. Kerala is high in two important dimension equitable spending between income group and efficiency of the use of resource. If we compare AP and Kerala, we find that it is the capital expenditure in AP that makes the difference. In terms of the quantity of physical infrastructure for primary healthcare, Kerala clearly scored over AP. However, since AP has already implemented NRHM norms and programs although it is not formally a part of the NRHM high focus states, it has started putting manpower in place and hence its additional recurring costs required to scale up the rural services works out to be much less than kerala. Andhra Pradesh had allocated a total of Rs.986 per capita on the healthcare in 2006-07. The figures for Kerala are very different. It allocated a total of Rs.1858 per capita on the same in 2006-07. The implications of scaling up health services in rural areas of these two states as given by NRHM estimates are that Andhra Pradesh needs to step up its allocation by almost 44% over 2006-07 in 2008-09 whereas kerala needs to step these up by 52%. Since these increases are not over one year, but two years, they are impossible to achieve though it is a challenging task.Planning commission report (2008) Reforms in the healthcare sector in Andhra Pradesh to review reforms in the health sector in India for reforms in the health sector in India. The Govt of India identifies the Healthcare sector reform and indicated the need in the eighth five year plan. The Eighth Five Year Plan (1992-1997) was the first document of the plan to indicate the need for the restructuring of rural healthcare financial systems, following the progress of the1990 macros. During this period in the health sector, the concept of free health care was revoked and requiring people to pay, even if partially, medical services. The ninth five year plan (1997-2002) emphasized the need to review the response of healthcare providers and the people themselves in the public sector, voluntary and private changing landscape of health, medical services reorganized to bring efficiency and about greater efficiency and to introduce reforms in the health system to enable people to obtain optimal care at affordable cost the ninth plan sought to increase volunteer involvement in organizations and the private effort in the provision of personal medical care and to ensure intersectoral coordination in the implementation of health programs and activities relating to health as well as allowing the Panchayati Raj

5

Institutions (PRI) in planning and monitoring of health programs at the local level to bring about greater awareness of health needs of people and greater responsibility to promote the coordination and use of local resources and community for health care. The Tenth Five Year Plan (2002-2007) slashing reforms in primary, secondary and tertiary health systems influence the policy significantly. The goals, priorities and strategies, changes in the committee are decided in large part to the political contingencies. There are demands for competition in health systems.Nirupam bajpai and sangeeta goyal (2004) in this study the authors said that about primary healthcare in India. India’s achievements in the field of healthcare have been less than satisfactory and the burden of disease among the Indian population remains high. Infant and child mortality and morbidity and maternal mortality and morbidity affect millions of children and women. Infectious diseases such as malaria and especially TB are reemerging as epidemics, and deaths can be prevented and/or treated cost-effectively with primary health care services provided by the public health system. An extensive primary health care infrastructure provided by the government exists in India. Yet, it is inadequate in terms of coverage of the population, especially in rural areas, and grossly underutilized because of the dismal quality of health care provided. In most public health centers which provide primary health care services, drugs and equipments are missing or in short supply, there is shortage of staff and the system is characterized by endemic absenteeism on the part of medical personnel due to lack of oversight and control. As a result most people in India, even the poor, choose expensive healthcare services provided by the largely unregulated private sector. Not only do the poor face the double burden of poverty and ill-health, the financial burden of ill health can push even the non-poor into poverty. On the other hand, population health is instrumental for both poverty reduction and for economic growth, two important developmental goals. India spends less than 1% of its GDP on public health, which is grossly inadequate. Public investment in health, and in particular in primary health care, needs to be much higher to achieve health targets, to reduce poverty and to raise the rate of economic growth. Moreover, the health system needs to be reformed to ensure efficient and effective delivery of good quality health services.

Kapil Yadav, Prashant Jarhyan, Vivek Gupta, Chandrakant S Pandav (2009) in this article the rural healthcare system of India is plagued by serious resource shortfall and underdevelopment of infrastructure leading to deficient health care for a majority of India. The differences in urban-rural health indicators are a harsh reality even today; infant mortality rate is 62 per thousand live births for rural areas as compared to 39 per thousand live births for urban areas (2007) only 31.9% of all government hospital beds are available in rural areas as compared to 68.1% for urban population. When the study consider the rural-urban distribution of population in India, this difference becomes huge. Based on the current statistics provided by the Government of India, the study have calculated that at a national level the current bed-population ratio for Government

6

hospital beds for urban areas (1.1 beds/1000 population) is almost five times the ratio in rural areas (0.2 beds/1000 population). Apart from this shortfall in infrastructure, shortfall in trained medical practitioners willing to work in rural areas is also one of the factors responsible for poor health care delivery systems in rural areas. There’s shortfall of 8% doctors in Primary Health Centres (PHC), 65% for specialist at Community Health centres (CHC), 55.3% for health workers (male), 12.6% for health workers (female) (2007).This shortfall in human resources in rural areas is only going to increase in future, more so with corporatization and privatization of health systems. The rural population of India still does not get the basic quality of primary health care as stated in Alma-Ata conference attended by governments of 134 countries and many voluntary organizations in 1978. “Primary health care is essential health care made universally accessible to individuals and acceptable to them, through their full participation and at a cost the community and country can afford”. T. Jamison, and Ramanan Laxminarayan(2007)This article from national rural healthcare mission in response to the challenge of sustaining the rural healthcare gains in the better-performing states and ensuring that lagging states catch up with the rest of the country, the Indian government has launched the National Rural Health Mission (NRHM). A central goal of the mission is to increase public expenditure on health from the current 1.1 percent of GDP to roughly 2-3 percent of GDP within the next five years. The NRHM has a clear geographical focus on rural areas, especially in the 18 states that have weak health outcomes and infrastructure, including nine particularly disadvantaged states, In this article, we examine the current status and future prospects of health financing in India in light of the NRHM. Much has been written on this issue and our contribution is to synthesize what is known in the context of the NRHM. NRHM objective is to draw attention to the benefits of public health spending, explore reasons why public spending has been much more effective at improving health outcomes in some regions but not in others, and to apply lessons learnt from the Disease Control Priorities Project-India or DCPP-India to the question of how best to deploy the new financial resources made available by the NRHM. The approaches of NRHM take in this article. One can consider health systems to have two broad objectives – to improve the level (and distribution) of health outcomes and to provide financial protection to the population, both from unanticipated large health expenditures and from income loss. Similarly, as a first approximation, one can consider health systems to have two types of resources at their disposal – financial and system capacity. DCPP-India and related efforts provide a good deal of quantitative information on the control of the shaded box – the financial costs of achieving health gains in different ways. S K Satpathy and S Venkatesh (2006) this article from The National Rural Health Mission (NRHM) is an ambitious strategy of the government. It aims to restructure the delivery mechanism for rural healthcare towards providing universal access to equitable, affordable and quality health care that is accountable and responsive to the people’s needs, reducing child and maternal deaths as well as stabilizing population, and ensuring

7

gender and demographic balance. The Mission is an articulation of the government’s commitment to raise public spending on health from 0.9% of India’s gross domestic product (GDP) to 23% of GDP and aims to undertake architectural correction of the health system. The Mission will enable the system to effectively handle increased allocation and promote policies that strengthen public health management and service delivery in the country. Wide ranging stakeholder consultations were held over a six-month period with state governments, the Planning Commission, the National Advisory Council, other government ministries/departments, health professionals and nongovernmental organizations (NGOs) to draw up the Mission strategy.Cardno healthcare Group Report(2009) This article was taken from Armenia primary healthcare model the implementing of Primary HealthCare Reform (PHCR) increase access to and demand for quality healthcare services; build sound health systems and structures; and improve utilization of financial resources in the health sector in Armenia. Healthcare emerging works with local and international partners to ensure efficient and effective delivery of health services to those most in need.Objective of Armenia primary healthcare: 1. Reform healthcare system policies and procedures nationwide2. Build clinical service capabilities through a family medicine approach3. Improve the quality of healthcare4. Foster improved healthcare seeking behavior through public healthcare education healthcare promotion activitiesHealthcare emerging ltd strengthens public and private sector institutions and systems, improves financial management, reforms budgetary procedures, implements innovative payment systems and performance-based rewards, and ensures transparency and accountability. Healthcare emerging ltd is implementing the basic set of interventions nationwide using a regional rollout methodADB (Asian development bank) (2007) in this article primary healthcare model development by ADB in Bangladesh (2006–2010) support for the rural primary healthcare sector development program. The Government of Bangladesh is supportive of ADB’s technical assistance (TA) to assess the achievements of the ongoing Primary Health Care Project (UPHCP) and to explore further support for health sector issues. This TA is part of ADB’s support to prepare the rural primary health care sector development program. As well as ADB finding some issues 1). The Government’s national poverty reduction strategy reaffirms that reducing poverty and accelerating the pace of social development are the most important long-term strategic goals. In the health sector, the strategy accords priority to improving maternal and child health care; delivery and supported by other development partners, ADB’s primary focus has been on the delivery of health care services in rural areas through public-private partnerships. 2). Public health encompasses multi-sector interventions. To maximize the development impact of healthcare outcomes in rural areas, 3). Prevention and promotion are more cost-effective in ensuring desired health outcomes. 4). Communicable disease prevalence continues to

8

be significant in Bangladesh. The Reason for this can be traced largely to poor food safety, poor sanitation and sewage infrastructure, weak solid waste and hospital waste management, and almost negligible waste water treatment. This review methodology part from institutional, policy, legal, regulatory and financial issues with regard to the ability of urban local bodies to execute their mandates on essential public health issues. The Technical assement also will compare the legal and regulatory frameworks relating to essential public health functions of urban local bodies with systems in middle-income countries,Trevor J.B. Dummer and Ian G. Cook (2008) the author said that about China and India are similarly huge nations currently experiencing rapid economic growth, ruralisation and widening inequalities between rich and poor. They are dissimilar in terms of their political regimes, policies for population growth and ethnic composition and heterogeneity. This review compares health and health care in China and India within the framework of the epidemiological transition model and against the backdrop of globalisation. We identify similarities and differences in health situation. In general, for both countries, infectious diseases of the past sit alongside emerging infectious diseases and chronic illnesses associated with ageing societies, although the burden of infectious diseases is much higher in India. Whilst globalisation contributes to widening inequalities in health and health care in both countries – particularly with respect to increasing disparities between urban and rural areas and between rich and poor – there is evidence that local circumstances are important, especially with respect to the structure and financing of health care and the implementation of health policy. For example, India has huge problems providing even rudimentary health care to its large population of rural areas dwellers whilst China is struggling to re-establish universal rural health insurance. In terms of funding access to health care, the Chinese state has traditionally supported most costs, whereas private insurance has always played a major role in India, although recent changes in China have seen the burgeoning of private health care payments. China has, arguably, had more success than India in improving population health, although recent reforms have severely impacted upon the ability of the Chinese health care system to operate effectively. Both countries are experiencing a decline in the amount of government funding for health care and this is a major issue.Ayesha De Costa and Vinod Diwan(2007) This article main aims to empirically demonstrate the size and composition of the private health care sector in one of India’s largest provinces, Madhya Pradesh., Methodology It is based on a field survey of all health care providers in Madhya Pradesh (60.4 million in 52,117 villages and 394 towns). Seventy-five percent of the population is rural and 37% live below poverty line. This survey was done as part of the development of a health system. Findings: The distribution of health care providers in the province with regard to sector of work (public/private), rural location, qualification, commercial orientation and institutional set-up are described. Of the 24,807 qualified doctors mapped in the survey, 18,757 (75.6%) work in the private sector. Fifteen thousand one hundred forty-two (80%) of these private physicians work in

9

urban areas. The 72.1% (67793) of all qualified paramedical staff work in the private sector, mostly in rural areas. The article empirically demonstrates the dominant heterogeneous private health sector and the overall the disparity in healthcare provision in rural areas. It argues for a new role for the public health sector, one of constructive oversight over the entire health sector (public and private) balanced with direct provision of services where necessary. It emphasizes the need to build strong public private partnerships to ensure equitable access to healthcare for all. Umesh Kapil Panna Choudhury (2005) the study explain about the healthcare infrastructure in India. The country has created a vast public health infrastructure of Subcentres, Public Health Centres (PHCs) and Community Health Centres (CHCs). There is also a large cadre of health care providers (Auxiliary Nurse Midwives, Male Health workers, Lady Health Visitors and Health Assistant Male). Yet, this vast infrastructure is able to cater to only 20% of the population, while 80% of healthcare needs are still being provided by the private sector. Rural India is suffering from a long-standing healthcare problem. This article Studies have explained that only one trained healthcare provider including a doctor with any degree is available per every 16 villages. Although, more than 70% of its population lives in rural areas, but only 20% of the total hospital beds are located in rural area. Most of the health problems that people suffer in the rural community. In this review of the above issues, the National Rural Health Mission (NRHM) has been launched by Government of India (GOI). It seeks to provide effective healthcare to rural population throughout the country. The NRHM will cover all the villages in these states through approximately 2.5 lakh village-based “Accredited Social Health Activists” (ASHA) who would act as a link between the health centers and the villagers. One ASHA will be raised from every village or cluster of villages, Methodology parts collect the data based on interview phase. Goals and strategies of NRHM. reduction in Infant Mortality Rate (IMR) and Maternal Mortality Ratio (MMR); (ii) universal access to integrated comprehensive public health services; (iii) prevention and control of communicable and non-communicable diseases, including locally endemic diseases; (v) population stabilization, gender and demographic balance; (vi) revitalize local health traditions and main-stream Ayurvedic, Yoga, Unani, Siddha and Homeopathy Systems of Health (AYUSH); Judith a. turner, Marcia a (2004) the author examined and identify predictors of healthcare use and prostatitis related and total healthcare costs for primary and secondary healthcare patients. And also primary objective of this literature review healthcare use and costs for men. The health care for prostatitis in large health maintenance. The Author used a comparison sample of randomly selected male healthcare maintenance enrollees matched by age and primary care provider to examine whether the use and costs for the prostatitis sample were approximately what would be expected for similar enrollees without a prostatitis visit. A second objective was to identify the predictors of high use and costs among patients with prostatitis. Compared with controls, patients with prostatitis had significantly greater total healthcare. The prostatitis costs were only a

10

small proportion of the total costs of the patients with prostatitis and of the difference in costs between patients with prostatitis and controls. The 10% of patients with prostatitis with the greatest total costs accounted for about one half of all costs. Health maintenance organization enrollees who seek care for prostatitis have greater total healthcare use and costs than do other enrollees of the same age and primary care provider. Most of the difference in costs reflects care for problems other than prostatitis. A small proportion of patients account for most of the costs. Methods. Compared the use and costs for 270 men the healthcare for prostatitis to those of randomly selected male health maintenance organization enrollees matched by age and primary care provider. D.Martin and H.Wrigley (2002) This article considers the problem of deriving realistic access measures between population demand and health service locations, in the context of a rural healthcare region of England. The article reviews approaches used in earlier work by the authors and others, and considers new public healthcare information systems that are now becoming available. An application is presented which incorporates the modeling of both private and public healthcare times for access to district general hospitals in Cornwall. This information has been assembled from published timetables in order to evaluate the use of more sophisticated access measures that might be used when such data becomes more generally available. The work is set within the context of an ongoing substantive research programme concerned with health outcomes in the rural South West of England.Gina M. Berg-Copas (2009) the purpose of this study was to develop a greater understanding of healthcare issues in rural area communities. These issues, identified as global in nature, also have been identified in rural area, a predominantly rural state. Public health departments that provide services to 2.9 million residents in 105 counties, in rural area there is wide variation in public health capacity across rural area, and rural areas have difficulty maintaining healthcare resources concerns identified by rural area community focus groups have legitimate and supported bases. The purpose of this focus group study was to identify community perceptions of healthcare needs of rural area and to understand better the perceived strengths and weaknesses of those communities. Community strengths included quality of life, community involvement, healthcare Facilities, agency collaboration, and commitment to healthcare worker recruitment. Weaknesses were language barriers, aging population, healthcare workforce availability, physician and spouse recruitment, access to medical, dental and mental healthcare, poor oral hygiene, and Community members identified several opportunities for rural area, including the high quality of life, agency collaborations, public health, However, external threats affected communities, including economic decline, out migration, poor farming industry, civic disinterest, growing rates of poverty, uninsured and vulnerable populations, high costs of health care, and funding shortfalls for primary level programs. Efforts should be directed towards healthcare professional recruitment, support for vulnerable populations, public healthcare programs, and inter-agency collaborations Methodology: Ten focus groups were conducted with rural community leaders.

11

Michael J. Garner, and Michael Birmingham(2008) This study focus on primary healthcare the use of complementary and alternative medicine has been increasing in Canada despite the lack of coverage under the universal public health insurance system. Physicians and other healthcare practitioners are now being placed in multidisciplinary teams, yet little research on integration exists. The author sought to investigate the effect of integrating chiropractic on the attitudes of providers on two healthcare teams. a mixed methods design with both quantitative and qualitative components was used to assess the healthcare teams. Assessment occurred prior to integration, at midstudy, and at the end of the study (18 months). Multidisciplinary healthcare teams at two community health centers in Ottawa, Ontario, participated in the study all physicians, nurse practitioners, and degree-trained nurses employed at two study sites were approached to take part in the study. A quantitative questionnaire assessed providers’ opinions, experiences with collaboration, and perceptions of chiropractic care. Focus groups were used to encourage providers to ommunicate their experiences and perceptions of the integration and of chiropractic. This project has demonstrated the successful integration of chiropractors into primary healthcare teams.H.M swami and vikas Bhatia(2005) This article explain about the primary healthcare over the decade the healthcare achievements made in the country through implementation of primary healthcare delivery system has resulted in longevity of life today India has 70 million elderly population over 60 year of age current health policies and programmes do not address significantly to improve their health status to the desired level, if the existing primary healthcare infrastructure in form of manpower and health centres are utilized. With some training to healthcare providers, the healthcare status of elderly can be improved. Initiation of the primary geriatric healthcare programm in India. In India the major thrust has been on improving the health status of children and women. Almost all the national programmes have been implemented either to control tropical diseases or are concerning maternal and child health besides family welfare. Over the years. Country has made substantial gains in not only improving health indicators but also developed extensive network of healthcare delivery system existing throughout the country. The author following methodology part base on primary data from primary sub centres and community healthcare centers S Wong, S Regan (2009) this article examined how to deliver primary health care (PHC) services and increase their accessibility from the patient’s perspective is needed. The author conducted seven focus groups with people living in rural communities, in British Columbia, Canada, as they reflected on priorities for and use of PHC. Equitable access to health care for all Canadians is a fundamental principle of the Canadian healthcare system. Healthcare systems that fail to provide equitable access for diverse populations can increase the gap in health disparities. Indeed, access to and utilization of primary healthcare (PHC) services is one pathway by which inequalities can influence population health, and equitable access to health services continues to be a common concern across geographic locations. For universally available health services, examining how to deliver

12

these services and make them accessible regardless of geographic location from providers’ and patients’ perspectives is needed. Studies have examined geographic access issues related to rural health care and services from the perspective of healthcare providers. However, less is known about how geographic access to PHC contributes to health disparities from individuals’ perspectives. The purpose of this study was to examine the perspectives of PHC of people who live in rural communities. Primary health care can be defined as an approach to health policy and service provision that includes both services delivered to individuals (primary care services) and population-level, public health-type functions. In terms of health service delivery, PHC is considered to be the place individuals first make contact with the healthcare system, and the first level of care that includes both clinical services and health promotion activities. While the PHC sector may be equitably distributed at a population level, the geographic location of rural communities compounds the extent to which these people are able to access timely and continuous PHC. In addition to discussing their priorities for PHC services, participants completed a brief questionnaire designed to collect information regarding socio-demographics, health status and utilization of primary healthcare providers. Descriptive statistics were obtained from questionnaire data. Focus group data were coded using an evaluation framework specifically developed for PHC; a thematic content analysis was then conducted on the coded data.Brijesh c purohit (2001) this article summarized the impact of structural adjustment in the Indian rural healthcare sector has been felt in the reduction in central grants to States for public health and disease control programmes. This falling share of central grants has had a more pronounced impact on the poorer states, which have found it more difficult to raise local resources to compensate for this loss of revenue. With the continued pace of reforms, the likelihood of increasing State expenditure on the health care sector is limited in the future. As a result, a number of notable trends are appearing in the Indian health care sector. The policy responses to these private initiatives are reflected in measures comprising strategies to attract private sector participation and management inputs into primary health care centres (PHCs), privatization or semi-privatization of public health facilities such as non-clinical services in public hospitals, innovating ways to finance public health facilities through non budgetary measures, and tax incentives by the State governments to encourage private sector investment in the health sector. Bearing in mind the vital importance of such market forces and policy responses in shaping the future health care scenario in India, this article examines in detail both of these aspects and their implications for the Indian health care sector. The analysis indicates that despite the promising newly emerging atmosphere, there are limits to market forces; appropriate refinement in the role of government should be attempted to avoid undesirable consequences of rising costs, increasing inequity and consumer exploitation. Stijn Claessens (2006) in this article the author reviewed discuss the evidence on the importance of rural healthcare finance for economic well-being. It provides data on the use of basic healthcare financial services by households and firms across a sample of

13

countries, assesses the desirability of universal access, and provides an overview of the macro-level, legal, and regulatory obstacles to access. Despite the benefits of healthcare finance, the data show that use of rural healthcare financial services is far from universal in many countries, especially developing countries. Universal access to healthcare financial services has not been a public policy objective in most countries and would likely be difficult to achieve. Countries can, however, facilitate access to financial services by strengthening institutional infrastructure, liberalizing markets and facilitating greater competition, and encouraging innovative use of know-how and technology. Government interventions to directly broaden access to rural healthcare finance, however, are costly and fraught with risks, among others the risk of missing the targeted groups. The article concludes with recommendations for global actions aimed at improving rural healthcare data on access and use and suggestions on areas of further analysis to identify constraints to broadening access. David h peters, k sujatha rao and Robert fryatt (2003): they were explaining. India’s health system was designed in a different era, when expectations of the public and private sectors were quite different. India’s population is also undergoing transitions in the demographic, epidemiologic and social aspects of health. Disparities in life expectancy, disease, access to health care and protection from financial risks have increased. These factors are challenging the health system to respond in new ways. The Old approach to national health policies and programmes is increasingly inappropriate. By analyzing interand intra-state differences in contexts and processes, we argue that the content of national health policy needs to be more diverse and accommodating to specific states and districts. More ‘splitting’ of India’s health policy at the state level would better address their health problems, and would open the way to innovation and local accountability. States further along the health transition would be able to develop policies to deal with the emerging epidemic of non-communicable diseases and more appropriate health financing systems. States early in the transition would need to focus on improving the quality and access of essential public health services, and empowering communities to take more ownership. Better ‘lumping’ of policy issues at the central level is also needed, but not in ways that have been done in the past. The central government needs to focus on overcoming the large inequalities in health outcomes across India, tackle growing challenges to health such as epidemic disease, and provide the much needed leadership on systemic issues such as the development of systems for quality assurance and regulation of the private sector. It also needs to support and facilitate states and districts to develop critical capacities rather than directly manage programmes. As India develops a more diverse set of state health policies, there will be more opportunities to learn what works in different policy environments Deepak Bhandari (2002) according to the author the state governments in the country have the necessary funds to invest in infrastructure development of secondary or tertiary level rural healthcare hospitals. Some States have received loans/grants from the World Bank (State Health System Development Projects in A.P , Karnataka , Maharashtra ,

14

Orissa, Punjab, U.P , Uttranchal & West Bengal ) to improve secondary level facilities. These improved facilities also tend to run down rapidly in the absence of adequately funded maintenance system and poor management systems. Public awareness of and expectations from health services provided by the government are rising rapidly. This is to an extent fuelled by the rapidly escalating cost of medical care provided by the private sector providers who constantly raise-the bar on the range and quality of healthcare services available in the country. The National Health Policy 2002 states “since 1983 the country has been seeing increase in mortality through ‘life-style’ diseases- diabetes, cancer and cardiovascular disease. The increase in the life expectancy has increased the requirement for geriatric care. Similarly, the increasing burden of trauma cases is also a significant public health problem”. There are little or no resources with the government to invest in facilities to take care of the increasing burden of these emerging diseases. It is estimated that in the next ten years the cost of caring for diabetic patients alone would cripple our economy. With the present state of economic health of State Governments and the increasing deficit in national budgets, it is unlikely that public sector allocations/spending on healthcare would register any increase. Most multi/ bi-lateral donour organizations (except for the World Bank) do not wish to invest in secondary or tertiary medical care services provided by the government in India.Vinod K. Diwan India has one of the most highly privatized health care systems in the world. The dominant private healthcare sector functions alongside a traditional tiered public healthcare sector. There has been an overall lack of collaboration between the two sectors despite international policy recommendations and local initiatives. It has been postulated that "conflicting perceptions" might contribute to the uncooperative attitude between the two sectors. But there has been little empirical exploration of the existing perceptions that the private and public health sectors have of each other. The study explored these perceptions among key stakeholders (who influence the direction of health policy) in the public and private health sectors in the province of Madhya Pradesh, India. The barriers of mistrust, which hinder true dialogue, are complex, and have social, moral, and economic bases. They can be best addressed by necessary structural change before any significant long-term partnership between the two sectors is possible (public and private).Papiya Mazumdar (2006) This article summarized the issue of rural healthcare has assumed greater significance in the developing world, mainly due to changing role of the state in providing health care. This article examines the levels, trends and patterns of public expenditure on health during 1995 to 2006 in India, both at the national and state levels. The study find that public expenditure on health as a proportion of GDP has remained stagnant over the years, and revenue expenditure accounting for the larger share. Among the states, the relatively poor ones were found to be spending more on health, both per capita and as a proportion of GSDP, compared to the richer states. It was seen that expenditure on health by the state had not grown adequately along the path of overall economic prosperity, and private out-of-pocket expenditure seemed to be on the

15

rise. The article cites a few alternative health financing strategies based on recent initiatives across the country, which needs to be reviewed with true intent, aiming equitable, unbiased and universal access to health care in the years to come.K. Kananatu (2000) this reviewed presents an overview of the India healthcare system and its method of financing. The development of the healthcare delivery system in India is commendable. However, the strength and weaknesses of the public healthcare system and the financing problems encountered are also discussed. Cost of healthcare and funding of both the public and private sectors were also revealed. One must optimise the advantages of operating a health financing scheme which is affordable and controllable which contribute towards cost-containment and quality assurance. Thus, there is a need for the establishment of a National Healthcare Financing, a mechanism to sustain the healthcare delivery network and operate it as a viable option. A model of the National Health Financing was proposed. Ravi Duggal (2007): The way in which healthcare is financed is critical for equity in access to healthcare. At present the proportion of public healthcare resources committed to healthcare in India is one of the lowest in the world, with less than one-fifth of health expenditure being publicly financed. India has large-scale poverty and yet the main source of financing healthcare is out-of-pocket expenditure. This is a cause of the huge inequities we see in access to healthcare. The article argues for strengthening public investment and expenditure in the health sector and suggests possible options for doing this. It also calls for a reform of the existing healthcare system by restructuring it to create a universal access mechanism which also factors in the private health sector. The article concludes that it is important to over-emphasize the fact that health is a public or social good and so cannot be left to the vagaries of the market.Melitta Jakab, Alexander Johannes Paul Jütting, and Anil Gumber (2002) according to the authors to provide empirical evidence regarding the performance of rural healthcare financing in terms of social inclusion and financial protection. Methods: five nonstandardized household surveys were analyzed from India (two samples), Common methodology was applied to the five data sets. Logistic regression was used to estimate the determinants of enrolling in a community-financing scheme. A two-part model was used to assess the determinants of financial protection: part one used logistic regression to estimate the determinants of the likelihood of visiting a health care provider; part two used ordinary least-squares regression to estimate the determinants of out-of-pocket payments. Findings: Social inclusion our findings suggest that community financing healthcare can be inclusive of the poorest even in the most economically deprived context. Nevertheless, this targeting outcome is not automatically attributable to the involvement of the community; rather it depends on key design and implementation characteristics of the schemes. Healthcare Financial protection community financing reduces financial barriers to health care as demonstrated by higher utilization and simultaneously lower out-of-pocket expenditure of scheme members controlling for a range of socioeconomic variables.

16

Nirvikar Singh (2008): This article examined delivery of public healthcare services in India, in the broader context of decentralization. It provides an overview of the basic features and recent developments in intergovernmental fiscal relations and accountability mechanisms, and it examines the implications of these institutions for the quality of public health service delivery. It then addresses recent policy proposals on the public provision of health care, in the context of decentralization. Finally, it makes suggestions for reform priorities to improve public healthcare delivery in this paper I discuss the nature of health care services and summarize the pattern of public-sector health spending in India. Then review the basic features of intergovernmental fiscal relations, recent developments, and accountability Mechanisms for the provision of sub national public goods. Next examine the impacts of the intergovernmental system and accountability mechanisms on the quality of public service delivery, including health care. Specifically address recent public policy proposals on the provision of health care, in the context of decentralization. Then offer a concluding assessment with suggestions for reform priorities to improve public health care delivery.Julian Schweitzer (2008) this article examined Focus on public healthcare finance and decentralization as central to resolving India's systemic public health crisis. However, some states and districts have achieved success despite serious financial and administrative deficits; this suggests that factors such as political commitment, community participation, human resource management, women's empowerment, and governance may be as or more important. The success of the National Rural Health Mission will depend on state and local institutional capacity, including strong partnerships with civil society organizations and private-sector actors. Increased resources and decentralization will not be sufficient by themselves. An examination of the failing districts will most likely reveal some systemic failures in developing the institutions and systems needed to ensure delivery of an integrated package of health services. These might include weak and inconsistent political commitment to improved services and better health outcomes for the poor; weak and divided community participation; poor hiring, management, deployment, and incentive systems for mid-level health workers and doctors. This would suggest that the success of the national rural healthcare mission will depend crucially on developing state and local institutional capacity, including strong partnerships with civil society organizations and private-sector actors. Additional money may be a necessary condition for success, but it will not be a sufficient condition if political commitment, governance, and administration are weak.Thomas C. ricketts (2000) : “National rural healthcare mission” in this article the author says The rural healthcare system has changed dramatically over the past decade because of a general transformation of healthcare financing, the introduction of new technologies, and the clustering of health services into systems and networks. Despite these changes, resources for rural health systems remain relatively insufficient. Many rural communities continue to experience shortages of physicians, and the proportion of rural hospitals under financial stress is much greater than that of urban hospitals. The health care

17

conditions of selected rural areas compare unfavorably with the rest of the nation. The market and governmental policies have attempted to address some of these disparities by encouraging network development and telemedicine and by changing the rules for Medicare payment to providers. The public health infrastructure in rural America is not well understood but is potentially the most fragite aspect of the rural healthcare continuum. The character of rural health care delivery in the 1990s has undergone significant changes caused by the rapid transformation of the U.S. health care system. Rural providers had functioned, like their urban counterparts, in a system dominated by fee-for-service payment mechanisms in which there were recognizable differences in the philosophies of public and private interests. In the 1990s, both public and private systems began to use managed-care principles to control costs, and an emerging emphasis on corporate and business philosophies began to blur the distinction between public and private healthcare systemsBoston Analytics reports (Jan 2009) in this article healthcare in India reports explore although India’s healthcare system has gradually improved in the last few decades, it continues to lag behind those of its neighboring countries. India’s healthcare infrastructure has seen steady improvement in the recent past, but much remains to be accomplished. Despite a steady increase in the number of medical establishments in the country, there still remains a severe shortage of sub-centers, primary health centers, and community health centers. Lack of adequate healthcare is also reflected in the low density of healthcare personnel. The public healthcare delivery system consists of a large number and a variety of institutions dispensaries, primary healthcare institutions, small hospitals providing specialist services, large hospitals providing tertiary care, medical colleges, paramedic training schools, laboratories, etc. Despite the size and reach of the public healthcare system, however, India scores poorly on most generally accepted health indicators. Boston Analytics reports (Jan 2009) according to this report the main objectives of public-private partnerships are to improve quality, accessibility, availability, acceptability, and efficiency of healthcare services. While different states in India have had different levels of success with implementation of such initiatives, it is expected that the private sector will continue to take on an increasing role in India’s healthcare system. Author follow methodology Each Boston Analytics Syndicated Research Report the wider scope of our specialized sector-specific questionnaires creates a rich data set to support extensive analysis. Syndicated Research Reports are based on monthly Boston Analytics Consumer Sentiment Index (BACSI) surveys of 3,000 respondents across four major Indian metropolitan areas Delhi, Mumbai, Kolkata, and Chennai. A stratified sampling process is adopted with the stratas based on the socio-economic conditions of the respondents to ensure a proper representation of the population. All data is collected via face-to-face interviews. The survey comprised 65% males and 35% femalesThe National Advisory Committee on Rural Healthcare (2000): These articles determine the small rural healthcare have led to the introduction of legislation that would

18

create a new Federal loan program for hospitals with under 50 beds. The program would also provide small grants for capital planning. There has been a lack of research on hospitals’ capital needs and on whether hospitals can currently access the capital needed to modernize their facilities. Concerns regarding the physical and financial condition of these hospitals motivated us to complete this study of small rural hospitals’ capital needs and access to capital. To gain insights into the capital needs of small rural hospitals, A list of 950 rural hospitals with under 50 beds was obtained from the American Hospital Association. The list was derived from the American hospital association’s national database of hospitals, which is designed to include hospitals that are not members of the national hospital association. These 950 hospitals were mailed a copy of the survey in mid-September 2001. A second mailing of the survey was sent in the middle of November 2001 to those hospitals that had not responded to the first mailing.Healthcare services infrastructure reports (2007): This report explain Rural Health care services infrastructure includes the physical facilities, personnel, administrative systems, and financial investments needed to deliver essential health services. Primary healthcare services represent a crucial entry point into the health care system. The adjusted primary care staffing ratio the ratio of population to full-time equivalent (FTE) primary care physicians in direct service provides an index of the availability of primary care. State’s health care services infrastructure delivers acute, primary, specialty, and long-term care. Infrastructure allows, but does not guarantee, access to services. It currently faces pressures from growing demand, the gap between rising costs and flat or declining revenue, and increasing numbers of uninsured patients. The collect data from national rural healthcare mission Johannes Paul Jütting (2000): “national rural healthcare mission in India” The objectives of the themselves. Furthermore, the potential social benefit of the schemes, that is, their impact on health care access, labor productivity, and households’ risk-management capacity, has been largely ignored. Community based healthcare schemes are becoming increasingly recognized as an instrument to finance health care in developing countries. Taking the example of less mutual health organization in rural Senegal, this review analyzes whether members in a mutual healthcare finance scheme have better access to health care than non-members. A binary probit model is estimated for the determinants of participation in a mutual and a logit/log linear model is used to measure the impact on Health care utilization and financial protection. The results that, while the health healthcare schemes reach otherwise excluded people, the very poorest in the communities are not covered. Regarding the impact on the access to health care, members have a higher probability of using hospitalization services than nonmembers and pay substantially less when they need care. Given the results of this study, community-financing schemes have the potential to improve the risk-management capacity of rural households. The modeling of mutual healthcare schemes’ impact on health care use and expenditure faces the important challenge of dealing with the problem of “endogenity” And “self-selection.” This problem is currently receiving a great deal of

19

attention in different areas of development economics, including measuring the impact of microfinance institutions, estimating the returns of education, and analyzing the impact of healthcare on various outcomes, Saltman and Ferroussier-Davis (2000): this study Determinants of Financial Protection, Health, and Social Inclusions Supply in health system and related sectors . There is a hierarchy of interest from non health sector factors in improving financial protection such as GDP, prices, inflation, availability of insurance markets, effective tax systems, credit, and savings programs to more traditional parts of the health system (a) preventive and curative health services, (b) health financing, (c) input markets, and (d) access to effective and quality health services (preventive, ambulatory, and in-patient). In respect to the latter, organizational and institutional factors contribute to the incentive environment of health-financing and service delivery systems in addition to the more commonly examined determinants such as management, The Healthcare Policy actions by governments, civil society, and the private sector. Finally, through their stewardship function, governments have a variety of policy instruments that can be used to strengthen the health system, the financing of services, and the regulatory environment within which the system functions this includes regulation, contracting, subsidies, direct public production, and ensuring that information is available. In countries with weak government capacity, civil society and donors can be encouraged to play a similar role.World Bank healthcare report (2000): In this study the author review assess the impact of scheme membership on healthcare financial protection in India; a two-part model was used. The first part of the model analyzes the determinants of using health care services. The second part of the model analyzes the determinants of health care expenditures for those who reported any health care use. There are several reasons for taking this approach. First, using health expenditure alone as a predictor of financial protection does not allow capture of the lack of financial protection for people who choose not to seek health care because they cannot afford it. As the first part of the model assesses the determinants of utilization, this approach allows us to see whether membership in community financing reduces barriers to accessing health care services. Second, the distribution of health expenditures is typically not a normal distribution. Many non spenders do not use health care in the recall period. The distribution also has a long tail due to the small number of very high spenders. World Bank development report (1993): this report explained Healthcare financing policy formulation in India, many of the international agencies had failed to encourage appropriate insurance-based alternatives to fee payment at the point of use. In particular, the 1993 World Development Report did not make recommendations for low-income countries that would change the situation in the short to medium term. Many national and international departments and agencies now accept that the principles of health insurance are applicable to low-income populations and are willing to study examples of insurance initiatives for poor and informal households. The outcome suggests that the design of community health insurance schemes may be improved by (a) design

20

specifications that utilize data on willingness to pay (WTP) of the target population and projected health care costs; and (b) incorporating modalities of operations that facilitate cost-effective exchange between a formal organization and individuals acting in an informal environment.Anil B. Deolalikar, T. Jamison, (2007): In this article, examine the current status and future prospects of rural health financing in India in light of the rural healthcare. Much has been written on this issue and our contribution is to synthesize what is known in the context of the rural healthcare. Our objective is to draw attention to the benefits of public health spending, explore reasons why public spending has been much more effective at improving health outcomes in some regions but not in others, and to apply lessons learnt from the Disease Control Priorities Project-India to the question of how best to deploy the new financial resources made available by the rural healthcare Given the large health and institutional disparities between group and non-group states, the financing challenges are quite different in the two groups. In gruop states such as Bihar, Madhya Pradesh, Rajasthan, Uttar Pradesh, and Orissa, which together account for 45 percent of India’s population, the health challenge is primarily high levels of infant and child mortality and child malnutrition. In contrast, in non-group states such as Kerala, Tamil Nadu and Gujarat, non communicable diseases are fast replacing infectious diseases and malnutrition as the leading causes of morbidity and mortality. These articles raise issues of service delivery in low-capacity settings. Issues of improving public-sector performance and leveraging the enormous capacity of the private health sector to successfully deliver health care are central to any health system, but we have devoted relatively less attention to these questions given our focus on health financing. The study discusses the mechanics of financing these health interventions and the implications for center-state financial responsibilities. The National Health Accounts (2001-02): the variations in health spending per capitaAcross states. Kerala has the highest annual per capita spending on health, followed by Haryana, Punjab, and Himachal Pradesh. At the other end, Assam, Orissa, and Rajasthan have the lowest levels of health expenditure per capita the share of private spending in total health spending across states. With the exception of Sikkim, private spending accounts for the major portion of health spending in every state. Suggests that there is no systematic pattern in the ratio of public expenditure on health to gross state domestic product. Public expenditure on health is low in relation to state income in relatively affluent states like Haryana and Gujarat as well as in a poor state like Uttar Pradesh. It is important to focus on a smaller subset of interventions that can be financed by the government and scaled up effectively for several reasons. Such as, much of the impact of public spending on health can be attributed to a handful of high-impact interventions, such as childhood. Immunizations. A similar set of health conditions are responsible for a significant proportion of the burden of disease. And formulating a simple package can be more effective than paying for a large range of health interventions without regard to joint costs or shared use of inputs These minimum packages have other advantages

21

simplifying planning of new investments in building and manpower, rural healthcare should focus on interventions that generate maximum levels of health gain and financial protection. Target interventions should address disease conditions that are major sources of under-five mortality and burden from infectious diseases,World Bank report (2005): in this report focus on improving health service delivery that have been discussed in the literature. Peabody (2006) summarizes these in the context of low- and middle-income countries:• Generate and encourage the use of specific clinical algorithms based on evidence of best practice.• Have service providers acquire skill and speed by doing a few things frequently rather than many things occasionally. Learning by doing is key to improving performance. This lesson is very relevant for India given the hard reality that, at least initially, the rural healthcare mission will have resources only for a limited set of high-priority items.• Improve provider incentives by creating a legal and ethical environment where-care providers do not profit personally from the sale of drugs, diagnostic procedures, or provision or referral of care. Overuse and misuse of resources typically flourish in such unethical environments.George R. McDowell: The findings of the study on the rural healthcare underserved by”National Association of Community Health Centers” provides some insight to the character and problem of health care and access to health care in rural India. To determine the number of underserved India, an index was created that included poor performance in health status, limited access to primary care physicians, or socioeconomic characteristics. The citizens in the communities in the lowest quartile were then considered to be underserved. The majority of the counties designated as underserved (73 percent), were so designated because of depressed health status rather than access to physicians. In rural counties, access to physicians was much more significant in determining underservice than in urban counties, although more than two-thirds of all rural counties were determined to be underserved by reason of depressed health status alone. There was, indeed, considerable variation in regions of the country in the determinants of medical under service. This suggests that the approaches to ameliorate problems in rural health care will vary from community to community or state to state. For example, where the problem of under service is associated with poor health status resulting from ignorance as much as access, then vigorous educational programs may contribute significantly. Conceivably both the health care problems associated with high infant mortality rates and morbidity from immunizable diseases could be partially addressed in this way. Conversely, where the problem is clearly one of access to primary care facilities or physicians, the approach will be much different. Interestingly, though not reported, the results of the national association of community healthcare center study indicate that 18 percent of urban (metro) people are medically underserved as compared to over 15 percent of rural people.

22

Kay A. Johnson (2006): This article look in rural healthcare Policy and finance barriers reduce access to preconception care and, reportedly, limit professional practice changes that would improve the availability of needed services. This study reviews barriers and opportunities for rural healthcare financing preconception care, based on a review and analysis of state and federal policies. This study describe states’ experiences with and opportunities to improve rural healthcare coverage, through public programs such as Medicaid, Medicaid waivers, and the State Children’s Health Insurance Program (SCHIP). And of community health centers in providing primary and preventive care to women also is discussed. In these and other public health and health coverage programs, opportunities exist to rural healthcare finance preconception care for low-income women. Three major policy directions are discussed. To increase access to preconception care among women of childbearing age, the federal and state governments have opportunities to: (1) improve health care coverage, (2) increase the supply of publicly subsidized health clinics, and (3) direct delivery of preconception screening and interventions in the context of public health programs.Jagdish Krishnappa, H V Sridevi and Dr U V Somayajulu (2006): Health care in India has improved in an impressive manner in the recent decades but undoubtedly it has been rural healthcare area due to the fact that about 75% of health infrastructure, the rural healthcare India faces the problem of burden of several morbidity patterns. This is reflected in the life expectancy (63 years), infant mortality rate (80/1000 live births), and maternal mortality rate (438/100000 live births). Given the limited health facilities available quality health-care is still beyond the reach of millions of rural healthcare masses. This can be considered as violation of basic human right of the people to have the benefit of quality health services. This also highlights the rural healthcare equity issues. The issue of rural health needs to be addressed both at macro and micro levels involving a coordinated, holistic approach so as to improve the health status in rural India. The National Health Policy addresses the prevailing inequalities, and promotes a long-term perspective plan, mainly for rural health. Launching of National Rural Health Mission (NRHM) in India in 2005 aiming at integrating different vertical programmes, decentralising health care service delivery at the village, and improving intersectoral action, was a major step in this direction. NRHM activities are also expected to help in substantial reduction in maternal and infant mortality from communicable diseases in the years to come. This article makes an attempt to understand the programmatic issues in rural health sector with specific reference to rural India and progress and review of NRHM in non-high focus large southern states of India, viz., Andhra Pradesh, Karnataka and Tamil Nadu. This article is based on the review of available literature and analysis of available secondary data.Winnie Yip and Ajay Mabal (2008): In this article the author explore the healthcare system of china and India Both China and India have recently committed to injecting new public funds into health care. Both countries are now deciding how best to channel the additional funds to produce benefits for their populations. In the study the author analyze

23

how well the health care systems of China and India have performed and what determines their performance. Based on the analysis, this article suggest that money alone, channeled through insurance and infrastructure strengthening is inadequate to address the current problems of unaffordable health care and heavy financial risk, and the future challenges posed by aging populations that are increasingly affected by noncommunicable diseases. To facilitate comparisons between China and India, the study adopt an analytical approach that is commonly used in evaluating health systems and designing health care reform.' This approach conceives of a health system as a set of relationships in which the structural elements of the system are causally connected to the goals of the system. Health status, financial risk protection, and public satisfaction, and the equitable distribution of each of these. The health system provides financial risk protection can be assessed by two metrics. The first measures the percentage of households in a population that are pushed below the poverty level as a result of out-of-pocket payments for health care. Existing evidence suggests that households in both China and India are vulnerable to financial shocks associated with ill health. A recent study shows that out-of-pocket health spending increases the percentage of people below the poverty level (US$1.08 per day) by nearly 20 percent in China, from 13.7 percent to 16.2 percent. In India, out-of-pocket spending increases the already high poverty rate of 31.1 percent to 34.8 percent, despite a smaller proportional increase compared to China.Sonia Bhalotra (2007) this study explained severe inequalities in healthcare in the world, poor healthcare being concentrated amongst poor people in poor countries. Poor countries spend a much smaller share of national income on health expenditure than do richer countries. What potential lies in political or growth processes that raise this share? This depends upon how effective government health spending in developing countries is. Existing research presents little evidence of an impact on childhood mortality. Using specifications similar to those in the existing literature, this article finds a similar result for India, which is that state healthcare spending saves no lives. However, upon allowing lagged effects, controlling in a flexible way for trended unobservable and restricting the sample to rural households, a significant effect of healthcare expenditure on infant mortality emerges, the long run elasticity being about -0.24. There are striking differences in the impact by social group. Slicing the data by gender, birth-order, religion, maternal and paternal education and maternal age at birth, the author find the weakest effects in the most vulnerable groups. The study micro-data are derived from the second round of the Nationa Family Health Survey of India (NFHS-2). These micro-data are merged by state and year of birth with a panel of data on health expenditure and other relevant statistics for the 15 Indian states.Giuseppe Pontoriero and Pietro Pozzoni (2007) The Italian national rural healthcare system funds universal healthcare through general taxation, but healthcare services are provided by local institutions. This article examines the epidemiology, provision, and funding of Renal replacement therapy (RRT) in Italy. In 2001, prevalence and incidence of RRT in Italy were 0.083% and 0.014%, respectively. Italy spends 8.3% of its GDP on

24

health care; 1.8% is for end-stage renal disease (ESRD) patients, who represent 0.083% of the general population. The reorganization of the NHS requires attention from the health community so that economic and geographic health disparities are not exacerbated. The characteristics of national health care organizations are inextricably associated with each country’s history and traditions, culture and social organization. In the world’s most industrialized countries, three main models of health care can be distinguished by the source of their funding (Lameire, Joffe, &Wiedemann, 1999). The first is the public or “Beveridge” model, which is funded by taxation and has a centrally organized national health system (NHS) that relies mainly on public health care providers: the budget for health care expenditure is centrally fixed and competes with the state’s other spending priorities. The second model is the “mixed” model, which is financed by compulsory premium-based social insurance and leads to a mixture of public and private providers, and more flexible funding. The third, the “private” model, is based on premiums paid by citizens to private insurance companies and leads to a system of mainly private providers in which the law of supply and demand governs health care expenditure; it is almost always constrained by regulation and affected by subsidies.Government of Belgium - Government of Tanzania (2008) this article main the aim of this article is to support Karagwe district in improving its Primary Health Care (PHC) services. The article focuses on three areas: improved financing of services through cost sharing/cost recovery instruments and insurances, improved quality of care through provision of drugs and medical supplies, improvement of skills of the PHC staff, . The community healthcare financing. The first half of 2008, a number of poor families were identified and exempted of Payment for the community healthcare financing exemption. The author following methodology part The Health services in Karagwe district are provided by the Government, by voluntary agencies and non-governmental organisations. There are three hospitals, three health centres and more than forty dispensaries in the district. Most of these health facilities have critical shortages of qualified staff. Health equipments are insufficient and often the infrastructure is poor.Charu C. Garg (1998) this article describes the financing and delivery of health care in India from viewpoint of equity. In this context typical financing mixes of public and private sources are examined. Inequity in delivery of health care is analyzed on the basis of utilization of health services by people in different income quintiles, and in different geographical locations on the basis of self-reported ill health. The study shows that even though the government sources of financing are mildly progressive, the large proportions spent by the household on health care makes it overall regressive. Both government and private expenditures are higher for higher income quintiles and for people living in urban areas and working in organized sector. On the other hand, people in lower income quintile and in rural areas bear higher burden of health expenditure as a proportion of their income. Delivery of health care is also found to be biased in favor of urban areas. The study mainly uses secondary data sources. Data on tax and non-tax revenues of the government are available from the Ministry of Finance, Government of India documents.

25

peter a. berman(1998) This studied examined Most developing countries have pursued formal health care system strategies which give primacy to government roles in financing and delivering health services. Despite decades of plans and investments based on this norm, the actual health care systems in many countries are quite different than what was intended or desired. Yet policies and plans continue to emphasize a statist approach. This article argues that, given the current situation in many countries, this long-term strategy to develop a “national health service”-type model of health care provision is misguided and wasteful. The current and potential role of nongovernmental health care providers in achieving high levels of access to basic services is highlighted, using data from an extensive analysis of health care financing and delivery in India. Major problems related to quality of care and the financial burden of unregulated fee-for-service medicine are also documented. India and Many other countries need to rethink their health care system development strategies to Acknowledge and build upon the opportunities offered by the already extensive nongovernment health care sector, rather than to view nongovernment services simply as a constraint to successful public programs. The article provides specific recommendations as to how this might be done. With the advice and financial assistance of international agencies, governments have pursued various strategies over the years to advance toward universal access. Public investment programs have typically led in the financing of institutions to train medical personnel, including physicians, nurses, and other allied health personnel, in keeping with international standards. Public financing has created and maintained national networks of hospitals organized in a publicly-defined and regulated hierarchy from local or community hospitals to tertiary-care facilities.eleven Asian country conferences(2005) The author examine the benefit incidence of public health care subsidies in eleven Asian country conference, including India, Indonesia and two provinces of China. The use of concentration indices and a high degree of consistency in the application of methods provide results that, unlike much of the existing evidence, are comparable across countries. Unlike many studies that examine utilisation data only or assume constant unit costs, the author exploit detailed health accounts to allow for variation in unit expenditures across health services, facilities and regions. And distinguish between hospital and non-hospital care and between inpatient and outpatient care. The examine not only the distribution of quantities of health care but also that of the value of subsidies. Hong Kong is the only territory that achieves a strong pro-poor distribution of all public health services. Public health care is more moderately pro-poor in Malaysia and Thailand and is evenly distributed in Sri Lanka. In the remainder of the low-income territories examined, the better-off receive more of the subsidy than the poor. The pro-rich bias is greatest in Nepal, Heilongjiang (China) and Indonesia, followed by India, Gansu (China), Bangladesh and Vietnam. The pro-rich bias is stronger for inpatient care than hospital outpatient care. In most territories, non-hospital care is pro-poor. But the greater share of the subsidy goes to hospital care and so this dominates the overall distribution. While public health subsidies are typically not pro-

26

poor, they are inequality reducing in all cases but for Nepal. This is because a given subsidy represents a greater proportionate increase in the living standards of the poor. Relative differences in welfare are narrowed. Hong Kong, Malaysia, Sri Lanka and Thailand have demonstrated that the allocation of sufficient public resources coupled with a policy of universal access can ensure greater benefits to the poor than is currently realised in many health systems throughout the developing world. Growing incomes not only make such policies more feasible, they also make them more effective, with respect to the target efficiency of spending, by availing the private sector. The authors examine individual utilisation of public health care in relation to living standards. Data are from the most recent official health or socio-economic surveys that provide information on both utilisations of public health care and a suitable measure of living standards. All are nationally representative but for the two surveys of Chinese provinces. Dileep V. Mavalankar (2008) this study explore about the Primary Health Care system in India is very large and covers almost all the parts of the country. It has more than 20,000 PHCs and 140,000 Sub-centres spread in more than 400 districts. This system consumes large amount of resources and is the system which provides the services for primary care including preventive programmes. The system is mainly managed by doctors, some of whom have brief public health training. This study argues that given the lack of training of doctors in management it is imperative that the doctors who are put in charge of the PHC system receive reasonable skills and training in management so that the resources spent on the PHC system can be utilised well - in an efficient and effective manner. Unfortunately the experience so far has been that there is hardly any systematic effort on adequate scale to meet the training needs of the PHC system for management training. The efforts done so far, even under the international supported projects are too less and of poor quality. It is also observed that most management training is very divorced from the day-to-day realities of the working of the PHC system and the kind of challenges they face. Finally the article argues that substantial efforts will be needed to be put in preparing doctors for the management posts in the PHC system. This will require large investments in training and linking training to practice in the field. The article also reviews available documents of the newer projects in health to see if there are indications that such training will happen in future. The article argues that there is a need for developing a separate health management cadre in India who will be trained in public health and health management to take up leadership role in PHC system in future.B. S. Ghuman and Akshat Mehta (2009) this study examines the problems and prospects of health care services in India. India as a nation has been growing economically at a rapid pace particularly after the advent of New Economic Policy of 1991. However, this rapid economic development has not been accompanied by social development particularly health sector development. Health sector has been accorded very low priority in terms of allocation of resources. Public expenditure on health is less than 1 per cent of GDP in India. It has further witnessed decline during the post economic liberalization period. The meagre resource allocation to health sector has adversely

27

affected both access and quality of health services. The unequal access to health services is reported across strata, gender and location (i.e. urban and rural areas). With a view to improve access and quality of health services, government should enhance public spending on health sector in the vicinity of 3 per cent of GDP. The top priority accorded to economic sector and marginal policy attention to social sectors like education and health results in economic prosperity accompanied by social poverty. Main objective of this to study the access of health services across economic strata, gender and space; to examine the quality of health services in India; and to suggest appropriate recommendations to revamp health policy and institutional mechanisms to improve access and quality of health services particularly for the excluded segments of society. Methodology follow the author the article largely depends upon secondary sources of data. The various sources of data include reports of the Union Ministry of Health and Family Welfare, the National Planning Commission, National Rural Health Mission, National Health Policies (1983 and 2002), Reports of the Nine Expert Committees constituted by the Government of India, etc. Primary data from an ongoing Project undertaken by the authors has also been used to supplement the findings arrived at from the secondary data.Melitta Jakab and Chitra Krishnan (2001) the study examined on healthcare community financing. The community financing is assess the performance of community involvement in health financing in terms of the level of mobilized resources, social inclusion, and financial protection; and establish the determinants of reported performance results, including technical design characteristics, management, organizational, and institutional characteristics. Community financing is an umbrella term used for several different resource mobilization instruments. The instruments vary in the extent of their prepayment and risk sharing, in their resource allocation mechanisms, organizational and institutional characteristics. Nevertheless, the common features they share include the predominant role of the community in mobilizing, pooling and allocating resources, solidarity mechanisms, poor beneficiary population, and voluntary participation. Performance of community-based financing. (i) Community financing mechanisms mobilize significant resources for health care. However, there is a large variation in the resourcemobilization capacity of various schemes. This review did not find systematic estimates about how much community financing contributes to health revenues at the local and/or national level. (ii) Community financing is effective in reaching a large number of low-income populations who would otherwise have no financial protection against the cost of illness. There is large variation in the size of various schemes. At the same time, there are no estimates about the total population covered through community financing. There are indications that the poorest and socially excluded groups are not automatically reached by community financing initiatives. (iii) Community-based health financing schemes are systematically reported to reduce the out-ofpocket spending of their members while increasing their utilization of health care

28

services. All studies with focus on community-based resource mobilization were included. The reviewed literature is very rich in describing the phenomenon referred to as community financing in terms of scheme design and implementation. Although this review found several systematic patterns of performance, there continues to be a need for a stronger evidence base regarding the performance of community-based resource mobilization mechanisms as health care financing instrumentsB. S. Ghuman and Akshat Mehta (2009) according to the author main objective of this article to examined the quality of health services in India; examined the problems and prospects of health care services in India. India as a nation has been growing economically at a rapid pace particularly after the advent of New Economic Policy of 1991. However, this rapid economic development has not been accompanied by social development particularly health sector development. Health sector has been accorded very low priority in terms of allocation of resources. Public expenditure on health is less than 1 per cent of GDP in India. It has further witnessed decline during the post economic liberalization period. The meager resource allocation to health sector has adversely affected both access and quality of health services. With a view to improve access and quality of health services, government should enhance public spending on health sector in the vicinity of 3 per cent of GDP. Data about health services has been collected from 352 households comprising 300 from the rural areas and 52 from the urban areas. For data analysis the suitable statistical techniques have been used.Dr. P. Murugesan, (2004) main objective of this study to provide trends and levels of the health system in India over period of time. At primary healthcare level Health and Socio-economic developments are so closely intertwined that is impossible to achieve one without the other. While the economic Development in India has been gaining momentum over the last decade, our health system is at crossroads today. Even though Government initiatives in public health have recorded some noteworthy successes over time, Building Health Systems that are responsive to community needs, particularly for the poor, requires politically difficult and administratively demanding choices. Health is a priority goal in its own right, as well as a central input into economic development and poverty reduction. Health sector is complex with multiple goals, multiple products, and different beneficiaries. India is well placed now to develop a uniquely Indian set of health sector reforms to enable the health system in meeting the increasing expectations of its users and staff. Managerial challenges are many to ensure availability, access, affordability, and equity in delivering health services to meet the community needs efficiently and effectively. In this paper, we describe the status of our health system, suggest a few health measures of maternal health indicators provided by three rounds of National Family Health Surveys (NFHSs), and conclude by identifying the roles and responsibilities of various stakeholders for building health systems that are responsive to the community needs, particularly for the poor. Poornima Vyasulu and V.Vijayalakkshmi(2001) the author said that on reproductive health services and role of panchayats in Karnataka the reproductive health care services

29

available to women in rural areas in Karnataka, and the various factors influencing them. Based on survey data on the status of Primary Health Centres (PHCs), and the availability of maternal health services, analyze the status of reproductive health services, their access and reach. This article also examines the role of Panchayati Raj Institutions (institutions of rural local government) in providing these services. Three sets of explanatory variables are used to examine maternal health care seeking viz. institutional structure quality of services; and social factors. The findings indicate that the resources available for health care are meager, particularly to Reproductive and Child Health (RCH) in rural areas. The primary source of funding for RCH is largely central government grants. Inadequate devolution of funds, functions, and functionaries contributed to panchayats not taking any significant initiatives to improve maternal health care. Umesh Kapil and Panna Choudhury (2005): according to the author in this study they have said that. The country has created a vast public health infrastructure of Subcentres, Public Health Centres (PHCs) and Community Health Centres (CHCs). There is also a large cadre of health care providers (Auxiliary Nurse Midwives, Male Health workers, Lady Health Visitors and Health Assistant Male). Yet, this vast infrastructure is able to cater to only 20% of the population, while 80% of healthcare needs are still being provided by the private sector. Rural India is suffering from a long-standing healthcare problem. Studies have shown that only one trained healthcare provider including a doctor with any degree is available per every 16 villages. Although, more than 70% of its population lives in rural areas, but only 20% of the total hospital beds are located in rural area. Most of the health problems that people suffer in the rural community and in urban slums suffer are preventable and easily treatable. In view of the above issues, the National Rural Health Mission (NRHM) has been launched by Government of India (GOI). The ASHA would be trained to advise village populations about sanitation, hygiene, contraception, and immunization; to provide primary medical care for diarrhea, minor injuries, and fevers; and to escort patients to medical centers. Taylor J, Wilkinson D & Cheers B: This study explores the relationships between rural places and community participation in health service development. Community participation in planning for health programs and services is fundamental to effective and accessible primary health care. It was found that community participants understood community participation as social interactions embedded in a community of place related to the betterment of the community. From this understanding three concepts about community participation in health activities emerge: • Community participation as development of place • The value of the community participation processes to the community • Community participation consistent with community values and attitudes. An understanding of the relationships between community functioning and community participation is essential for health professionals working with communities and for communities themselves. It may important in developing community-based initiatives in other fields such as social care and environmental management.

30

C. John Clements, Pieter H. Streefland and Clement Malau (2007):this study explore about the primary healthcare. There is nothing new about supervision in primary health care service delivery. Supervision was even conducted by the Egyptian pyramid builders. Those supervising have often favored ridicule and discipline to push individuals and communities to perform their duties. A traditional form of supervision, based on a top-down colonial model, was originally attempted as a tool to improve health service staff performance. This has recently been replaced by a more liberal “supportive supervision”. While it is undoubtedly an improvement on the traditional model, we believe that even this version will not succeed to any great extent until there is a better understanding of the human interactions involved in supervision. Tremendous cultural differences exist over the globe regarding the acceptability of this form of management. While it is clear that health services in many countries have benefited from supervision of one sort or another, it is equally clear that in some countries, supervision is not carried out, or when carried out, is done inadequately. In some countries it may be culturally inappropriate, and may even be impossible to carry out supervision at all. We examine this issue with particular reference to immunization and other primary health care services in developing countries. Supported by field observations in Papua New Guinea, we conclude that supervision and its failure should be understood in a social and cultural context, being a far more complex activity than has so far been acknowledged. Social science based research is needed to enable a third generation of culture-sensitive ideas to be developed that will improve staff performance in the field.WHO (2000) proposes that primary health care review can be at seven levels - National, District, Health Centre, Community Health Workers, Community Leaders and Household levels. “The main objectives of a review is to identify the strengths and weaknesses of a national programme inorder to establish or adjusted priority and to make specific recommendations for future action" (WHO, 2000. P.3).Aspects to be covered in a review of primary health care as outlined by WHO are:"1. Health aspectsThe health aspects involved an evaluation of the process, output and impact of the PHC programme from the health sector perspective, using various indicators that reflect the results in terms of health sector performance, health activities output with respective individual programme and the health impact.2. Social aspectsThe social aspects involve an evaluation of community involvement in health, including the influence of people at all levels in bringing about better health, the outcome in terms of community satisfaction and human resources development at the community level.3. Intersectoral aspects................... this includes an assessment of how the contributions of other sectors, are affecting the health of the people ..........". (WHO 2000, pp. 2-3)

31

In the proposed study review of Primary Health Care programme can be conducted at health centre, community health workers, community leaders and household levels as proposed by WHO (1992). Bharti Birla, Udita Taneja(2006) this study said that about Public Private Partnerships for Healthcare Delivery in India: Assessing Efficiency for Appropriate Health Policies Healthcare delivery is a major concern for India and other developing nations. A number of Public Private Partnerships (PPPs) have entered the arena of healthcare delivery. These partnerships are based on different models. The efficiency of such partnerships needs to be assessed as it will help formulate policies that can contribute in enhancing the role of such partnerships in meeting the health goals of the country. There are several factors that govern the efficiency of such partnerships. The present study aims to identify the factors that are considered important while assessing the efficiency of healthcare delivery units based on PPPs, and to rank these factors.AMLAN MAJUMDER V. UPADHYAY(2004): this study focused on the an analysis of the primary health care system in India with focus on reproductive health care services The health care system in India, at present, has a three-tier structure to provide health care services to its people. The first tire, known as primary tire, has been developed to provide health care services to the vast majority of rural people. The primary tire comprises three types of health care institutions: Sub Centre (SC), Primary Health Centre (PHC) and Community Health Centre (CHC). The rural health care infrastructure has been developed to provide primary health care services through a network of integrated health and family welfare delivery system. India is a signatory to the Alma Ata Declaration of 1978 and was committed to attaining the goal of “Health for All by the Year 2000 A.D" through the universal provision of primary health care services (Government of India, 1983). However, India could neither achieve reproductive health related goals (Srinivasan, 2000 and Sood, 2000) nor could develop a good health care infrastructure for rural people (Majumder, 1999). Productivity, efficiency and quality of care of public rural health service sector have always been questioned from many different fields. The present study makes an attempt to reveal the true condition of the system by examining the relationship between efforts and accomplishments in primary healthcareAlexander S. Preker, Guy Carrin,(2006) this study explaining about the healthcare community finance schemes have evolved in the context of severe economic constraints, political instability, and lack of good governance. Usually government taxation capacity is weak, formal mechanisms of social protection for vulnerable populations absent, and government oversight of the informal health sector lacking. In this context of extreme public sector failure, community involvement in financing health care provides a critical, though insufficient, first step in the long march toward improved health care access for the poor and social protection against the cost of illness. It should be regarded as a complement to not a substitute for—strong government involvement in health care financing and risk management related to the cost of illness. Based on their extensive

32

survey of the literature, the authors show that the main strengths of community-financing schemes are the extent of outreach penetration achieved through community participation, The authors conclude by proposing concrete public policy measures that governments can introduce to strengthen and improve the effectiveness of community involvement in health care financing. These include: (a) increased and well-targeted subsidies to pay for the premiums of low-income populations; (b) use of insurance to protect against expenditure fluctuations and use of reinsurance to enlarge the effective size of small risk pools; (c) use of effective prevention and case management techniques to limit expenditure fluctuations; (d) technical support to strengthen the management capacity of local schemes; and (e) establishment and strengthening of links with the formal financing and provider networks. Aaron Katz and Jack Thompson (2006) the study said that about The Role of Public Policy in Health Care Market Change Market forces appear dominant in the transformation of health care systems across the United States. However, in many markets public policy remains an important factor-guiding, facilitating, and in some cases prompting change. This study reviews how the debate over health care reform acted as a catalyst in local health care financing and delivery systems, and how other public policy tools are affecting the fifteen markets studied in the Community Snapshots project. We then discuss prospects for public policy in the near term and the longer term, using two scenarios to illustrate possible future roles.amlan majumder v. upadhyay(2004) this study saying about rural healthcare role in India, The health care system in India, at present, has a three-tier structure to provide health care services to its people. The first tire, known as primary tire, has been developed to provide health care services to the vast majority of rural people. The primary tire comprises three types of health care institutions: Sub Centre (SC), Primary Health Centre (PHC) and Community Health Centre (CHC). The rural health care infrastructure has been developed to provide primary health care services through a network of integrated health and family welfare delivery system. India is a signatory to the Alma Ata Declaration of 1978 and was committed to attaining the goal of “Health for All by the Year 2000 A.D" through the universal provision of primary health care services (Government of India, 1983). However, India could neither achieve reproductive health related goals (Srinivasan, 2000 and Sood, 2000) nor could develop a good health care infrastructure for rural people (Majumder, 1999). Productivity, efficiency and quality of care of public rural health service sector have always been questioned by scholars from many different fields. The present study makes an attempt to reveal the trueCondition of the system by examining the relationship between efforts and accomplishments.Robert J. Parsons, Bruce P. Murray, and Richard B. Dwore (2003): This article describes the results of a literature search of pertinent professional literature written on issues important to rural healthcare delivery in the United States. Rural healthcare delivery has become, in many respects, a major national concern during the past decade.

33

Problems include the continuing and marked exodus of healthcare providers and organizations from “rural” and “pioneer” regions of the country, the numerous federal and state initiatives intended to insure the availability of healthcare services and providers in rural communities and show government commitment to rural health issues, and the increased emphasis on memberships to rural health and healthcare delivery by the respective healthcare provider professional and affiliate associations. Overall, significant and salient issues facing healthcare providers and administrators in the rural sector during the 1990s have made rural healthcare delivery increasingly more complex and difficult to handle while proving that it will be one of the toughest challenges that the entire American system of healthcare delivery will face in the new millennium. Solutions to rural healthcare problems are likewise illusory. The rural hospital, the bastion and central focus of rural healthcare delivery for half a century, is under siege in many areas, the most threatening being an inability to survive financially. Without the proper funding, it is impossible for these rural hospitals to deliver the quality and variety of care that concern rural patients. Furthermore, a lack of funds creates different concerns for each of the stakeholders, i.e., the rural practitioners, patients, and healthcare administrators. However, the Federal Government has through the critical access hospital program provided funding to improve the status of rural hospitals.

As Creese (1991, p.318) opines "Fees in the health sector are thus not an instrument of health policy, but a means of fiscal policy, with the health ministry being a tax collecting agency”. However, efforts have been made to overcome some of the problems associated with user fees. For instance, in another study in Kenya by Collins et al (1996), it was indicated that the implementation of user fees in phases according to the level of facility (national, provincial,district and sub-district hospitals and health centres) led to better acceptance both by the providers and patients. The phased implementation backed by the development of better management systems helped to reduce the decline in demand and revenue collections improved. The improved management system included steps like the preparation of cost sharing operation manuals, and staff training for procedures pertaining to patients’ claims, cash collections, waivers, exemptions, accounting and reporting etc. Likewise, anomalies in exemptions like free services to civil servants were replaced by new medical allowance to the civil servants. The phased implementations downward from the apex referral hospital as well as the retention incentive created by appropriate management training helped to improve collections. However, the results of the management training input did not indicate a consistent improvement in quality of services (Collins et al, 1995). Jagdish Krishnappa, H V Sridevi and Dr U V Somayajulu(2007) Health care in India has improved in an impressive manner in the recent decades but undoubtedly it has been urban-centric due to the fact that aout 75% of health infrastructure, human resources and other resources are concentrated in urban areas where only 27% of the population lives. The rural India faces the problem of burden of

34

several morbidity patterns. This is reflected in the life expectancy (63 years), infant mortality rate (80/1000 live births), and maternal mortality rate (438/100000 live births). Given the limited health facilities available quality health-care is still beyond the reach of millions of rural masses. This can be considered as violation of basic human right of the people to have the benefit of quality health services. This also highlights the health equity issues. The issue of rural health needs to be addressed both at macro and micro levels involving a coordinated, holistic approach so as to improve the health status in rural India. The National Health Policy addresses the prevailing inequalities, and promotes a long-term perspective plan, mainly for rural health. This study makes an attempt to understand the programmatic issues in health sector with specific reference to rural India and progress and review of NRHM in non-high focus large southern states of India, viz., Andhra Pradesh, Karnataka and Tamil Nadu. This study is based on the review of available literature and analysis of available secondary data. The review indicates progressive trends in terms of NRHM implementation and its impact. For instance, in Karnataka, there is an improvement in institutional deliveries from 60% in 2005 to 72% December 2007. The crude birth rate (CDR) reduced from 20.6 to 19.6 during 2005- 2008, while IMR declined to 47/1000 live births from 50/1000 in 2005.Government of India, (1999): The study reveals that utilization of services depends on a number of factors. Planning Commission (Government of India, 1999) evaluated functioning of the CHCs taking into account availability and accessibility factors (area coverage of a CHC, total number of Doctors in a CHC, per cent of specialists present in CHC, mean distance of PHC from the CHC). It has explained 71 per cent of variation in utilization of services by these variables. The study did not consider factors related family characteristics and social structure.(Sodani 1997, 1999) has estimated demand functions for health care for the region of Rajasthan. Though he has taken into account 11 independent variables (age, education, time gap, duration of illness episode, number of visits, distance, income, number of rooms, family size, highest level of education among males and highest level of education among females), the author has not included availability factors. After the International Conference on Population and Development in 1994 (ICPD) at Cairo, quality of care is coming to be acknowledged as equal in importance with access to reproductive health services. Delivering successful care involves respects for the individual needs and rights of the clients, and useful service from the staff in hygienic conditions (UNFPA, 1994, 1995). This review has not revealed any study on Indian family planning incorporating primary health care system to address the issue of quality of care. This paper makes an attempt to include variables from all the categories: availability, accessibility, family characteristics, social structure and quality of care.Worthington, (2004): The report of the Australian Steering committee for the Review of Common-wealth/State Service Provision (1997), defines the efficiency of a healthcare unit as the degree to which the observed use of resources to produce outputs of a given quality matches the optimal use of resources to produce outputs of a given quality.

35

According to Worthington, there can be three main measures of the efficiency of healthcare units. These are technical efficiency , allocative efficiency and productive efficiency. Technical efficiency , as the name suggests, pertains to the use of produc-tive resources in the most technologically efficient manner, i.e. getting maximum possible output from a given set of inputs. Allocative efficiency on the other hand measures the ability of the organization to select different efficient combination of inputs to produce the maximum possible outputs (Worthington, 1999). Farrell and Worthington, state that technical and allocative efficiency taken together determine the degree of productive efficiency (also called economic efficiency) (Farrell,1957; Worthington, 2004). Worthington points out that an organization is said to have achieved total productive efficiency (economic efficiency) if its resources are used completely allocatively and technically efficiently. Conversely, if the either allocative or technical inefficiency is present, then the organisation will be operating at less than total economic efficiency (Worthington, 2004). Kooreman, (1994). A number of studies have been conducted worldwide, and a few in India, to calculate the efficiency of healthcare units. In these studies a number of input and output factors have been considered while calculating the efficiency of the unit. Many health-care studies in India and abroad have defined different input factors, such as number of doctors, number of nurses/paramedical staff, cost of supplies, and cost of high-cost technical machinery. Some of the outputs selected are number of regular ad-missions, number of surgeries, case mix categories, and number of discharges. Apart from these quantifiable factors, Kooreman states that efficiency is also a measure of some hard to quantify factors, such as improved health status or im-proved quality of life (Kooreman, 1994).Medical and Public Health(2008) study main Primary objective of the State is to actively promote the Welfare of the people by extending promotive, preventive, curative and rehabilitative health care services. To achieve the objective, the state has taken steps to improve the health care delivery system so that it can reach the poorest section of the society by construction of buildings to provide more beds, provision of sophisticated equipments, providing specialized services, enhancing the strength of the medical as well as paramedical personnel and by improving the quality of services rendered.The important objectives of the Health and Family Welfare sector are as follows:• To provide effective tertiary care to all sections of the public by making available the modern medical techniques and technologies in Government teaching hospitals• To provide research relevant to human development and quality of life• To increase the access and utilization of health services, particularly among the unreached and underserved population• To design and implement the effective interventions in the area of Maternal and Child Health to reduce IMR and MMR to the expected levels

36

• To Implement schemes for prevention and control of communicable diseases and non-communicable diseases with special focus on newly emerging vector borne diseases and life style diseases• To create awareness and to ensure timely availability of accident and trauma care services to reduce morbidity and mortality Johns1 and Ron Labonte2Madhurim nundy(2000) the study explain about the Primary Health Care in India: Review of Policy, Plan and Committee Reports The Alma Ata Declaration in 1978 gave an insight into the understanding of primary health care. It viewed health as an integral part of the socioeconomic development of a country. It provided the most holistic understanding to health and the framework that States needed to pursue to achieve the goals of development. The Declaration recommended that primary health care should include at least: education concerning prevailing health problems and methods of identifying, preventing and controlling them; promotion of food supply and proper nutrition, and adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunization against major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; promotion of mental health and provision of essential drugs. It emphasized the need for strong first-level care with strong secondary- and tertiary-level care linked to it. It called for an integration of preventive, promotive, curative and rehabilitative health services that had to be made accessible and available to the people, and this was to be guided by the principles of universality, comprehensiveness and equity. In one sense, primary health care reasserted the role and responsibilities of the State, and recognized that health is influenced by a multitude of factors and not just the health services. It also recognized the need for a multisectoral approach to health and clearly stated that primary health care had to be linked to other sectors.Catherine hurely (2009) this study To identify the extent to which the Alma Ata defined Comprehensive Primary Health Care (CPHC) approach is practised and evaluated in Australia and to describe the role that GPs and other medical practitioners play in it along with implications of this for future policy in light of the Health and Hospital Reform Commission (HHRC) and Primary Health Care taskforce reports, 2009 ecommendations. In Australia, the CPHC approach occurs chiefly in Aboriginal Controlled Community Health Services, state funded community health and in rural/remote and inner city areas. Participation by GPs in CPHC is limited by funding structures, workforce shortages and heavy workloads. Factors that facilitated the CPHC approach include flexibility in funding and service provision, cultural appropriateness of services, participation and ownership by local consumers and communities and illingness to address the social determinants of health. The recent HHRC and Primary Health Care Taskforce reports recommend an expansion of CPHC services as a means of tackling health inequities. The findings of this A renewed research and policy focus on CPHC was also evident. One such effort was the “Revitalising Health for All” (RHFA) research and capacity building project funded by the Canadian Global Health Research Initiative the study was

37

conducted a narrative review of the literature (published and grey) from 1987 to mid 2007 as part of a global review carried out by teams of researchers in six regions in 2007.Ministry of Health, china (2005) : The study explain about the Costs and efficiency in china rural healthcare system A variety of indicators suggest low levels of efficiency in China’s health sector. Bed occupancy rates are low: the average for all hospitals in China is just over 60%; in THCs, the figure is below 40%. In the established market economies of the Organisation for Economic Cooperation and Development (OECD), the average is nearly 80%.The productivity of health staff is also low, with relatively few patients seen per day (about 5 outpatients per doctor and 1.5 inpatient beddays per doctor for generalacute hospitals in 2004) (Ministry of Health, 2005). Low-capacity utilization raises costs above the feasible minimum, although how far is not known and so does the provision of unnecessary care: one study found that 20% of all expenditure associated with appendicitis and pneumonia treatment was clinically unnecessary (Liu and Mills, 1999). In part this was because of excessive drug spending (onethird of drug expenditures were considered to be unnecessary by a panel of reviewing physicians), but it was also due to overly long hospital stays (the panel concluded that, for both conditions, length of stay could be reduced by 10–15% without any adverse effects on health outcomes). Levels of productivity also appear to be stagnating or falling. Since the 1980, the number of providers has increased while caseload has been falling (Ministry of Health, 2004). Bed-occupancy rates were, as a result, falling, especially in THCs, at least until 2000, with slight improvements since then (Ministry of Health, 2005). The number of patients treated per provider per day has also fallen in rural areas.Amir Ashkan Nasiripour, Behrooz Rezael and Mohammad Hosein Yarmohammadian(2009): the study explain about A comparative study of primary health care management in selected countries and designing a model In this research Primary Health Care systems were reviewed and the nurses' roles were determined and then a model was designed for health networks in Iran. This was a triangulation research done in comparative method. In first step, PHC systems reviewed in different countries such as UK, Australia, Canada, Sweden and Turkey selected in purposive sampling. In second step, the process of management of PHC services in selected countries were determined from accessibility, providers and referral system, and then compared to PHC system in Iran. Afterward a primary model was designed. In all of the studied countries, PHC services were delivered by health team including family physicians, nurses, midwives, and health technicians in systematic network including local health centers, family physicians offices and nursing clinics. Family physicians and nurses had a basic role in delivery of services. Also other health practitioners such as psychiatrists were practiced with health team. PHC services in most cases on the bases of people's need and health information were transmitted between the providers by health files. The effective referral system exists between health services. The model of PHC delivery was on the bases of health team with systematic network of the local health centers and provides

38

accessibility, quality and comprehensively of services. We suggest to employee educated nurses in health centers to provide more health services.

RURAL HEALTHCARE DELIVERY MODELS DEVELOPED CONTRIESIRELAND The Irish care system is characterised by universal free eligibility to acute care funded by general taxation. Despite this universal eligibility, approximately 64% of the population choose to purchase private medical insurance. An esri study showed that the main reason why people choose private medical insurance is to be assured of timely access to hospital should they need treatment. Private healthcare insurance currently allows insured persons to effectively skip the waiting lists that exist in the public system the state provides free primary care to approxiely 1/3 rd of the population on a means tested basis for the balance of the population primary care is paid for out of pocket with only limited insurance coverage. Primary care. And in particular the general practitioner practitioner acts as a gatekeeper to secondary care the patient comes to their GP in the first instance .who may prescribe medication recommend continued primary care or refer to a specialist for possible admission to hospital the large single purchase of primary healthcare services in Ireland is the state. There balance of the population who are not entitled to benefit under the gms scheme may receive a contribution from the state toward their primary healthcare costs, through the drugs payement scheme where by prescribed drugs in excess of set level of expenditure are dispensed free of chargeUK The UK healthcare system is characterished by universal free eligibility to acute care and primary care funded by general taxation. The fact that only maximum 13% of the population choose to purchase private medical insurance is testament to the comprehensive cover provided by the nhs however waiting lists on the nhs are substantial there are more than 1 million people on waiting lists for in patient and day patient treatment, and more than 64000 have been on waiting list for more than 1 The state is by far largest purchase of primary healthcare services in the UK under the national healthcare system everyone is entitled to free general practices (gp) services although a limited private market exists. Patients must register with a selected gp.practice which becomes responsible for their primary healthcare needs and referral to hospital care where required.

AUSTRALIAThe Australia healthcare system is probably the most similar to the irish system. Public healthcare is provided to all all through the Medicare system, which is funded by taxation everyone is entitled to Medicare covers hospital costs, and the bulk of general practices costs, but does not cover other primary healthcare treatments.

39

Private healthcare insurance is voluntary. In 1983 when universal access to Medicare was introduced, the proportion of the population with private health insurance decreases from 64% to 50%. Since then high escalation with private health insurance premiums and substantial balance billing, has resulted in a steady decline in the number opting foe private healthcare insurance. The proportion is approximately 34% at present. As a consequence of the reduced popularity of private healthcare insurance. Demand pressure on the public system is growing, and the public healthcare budget is under severing pressure. Reforms to the system are under consideration. In respect of in-patient treatment of private patients. Medicare subsidises 75% of the minimum benefits scheduled and the balance is met by the insurance company. This contrast with the Irish system, where there is not direct payment to private hospitals by the state for private patients, who are foregoing their entitlement to public trearment source of payement of this country the state is main source of funding for primary healthcare Medicare cover the bulk of general practices costs. The state also subsidises the cost of pharmaceuticals USAThe healthcare system which operates in the usa is quite different from the other countries examined, in that free public healthcare applies to only a small proportion of the population, and private healthcare insurance is voluntary.A free public healthcare services for the over 65 age group and the disabled. Medicare was introduced in 1965, a further free public healthcare services, Medicaid was introduced for the low income population. Medicare and Medicaid in total cover approximately 22% of the population. The remaining 78% of the population are not entitled to free public healthcare services.Many states contract out the provision of care under Medicare to private .The state pays insurenrs a risk adjusted capitation payment per enrollee. The insurers compete for business on the basis of service provided, treatment covered, and level of co-payments.SINGAPORE:We chose Singapore of further research because of the fundamental difference in the philosophy of the Singapore government regarding the provision of health care services. Compared to the philosophy of European governments.To quote from a white paper issued by the ministry of Health in Singapore:“Our health care financing is based on individual responsibility, coupled with Government subsidies to keep basic health care affordable. To avid the pitfall of “free”medical services which they use and pay more when they demand a higher level of service.”“We must rely on competition and market forces to impel hospitals and clinics to run efficiently, improve services and offer patients better value for money. When hospitals are insulated from price signals and market forces, the potential for inefficiency and waste is enormous. “MOH will define the basis medical package which all Singaporeans will have access to……..The treatment will be delivered without frills by trained personnel using

40

appropriate facilities. It will exclude non-essential or cosmetic services, experimental drugs and techniques whose effectiveness is not yet proven and extravagant efforts to keep gravely ill patients alive using high technology equipment, regardless of their quality of life and prospects of recovery.”We expect that these kinds of statements from government would be totally unacceptable in many European countries. The philosophy of the Singaporean government toward the provision of health care could be described as the opposite of the paternalistic philosophy of many European states.The Singaporean government subsidises public hospitals. However, co-payments are required in respect of even heavily subsidiesed hospitals.SWEDEN: Sweden has high standard of health when compared to other European countries. With infant mortality among the lowest and life expectancy among the highest. Treatment is primarily hospital based with no clear distinction between primary and hospital based care. There is no recognized system of family doctors and members of the public are free to refer themselves directly to hospitals in their region. The provision of hospital services is the responsibility of local county councils.The health care system is predominately state owned and run. Local county councils are responsible for the funding of their local hospitals through the collection of regional income taxes. State grants are also allocated based on a weighted capitation scheme. Funding is also raised through the National Insurance Scheme. Which is is compulsory for all members of the population over age 16. The National Insurance Scheme reimburses patients directly for services covered under the scheme.Approximately 11% of the total spend on healthcare in 1991/1992 was from patient co-payments. Co-payments apply on most services with an overall annual maximum co-payment applying per individual.The insurance market is very small, covering co-payments to physicians and access to a limited number of private hospitals and physicians. Most GPs are public primary care physicians and are salaried employees of local county councils. No system of family doctors operates and different GPs may treat patients on each visit to their local care centre. GP wages are negotiated with Government on an demand cannot be met from normal working hours. There are a small number of GPs who operate a private practice only. They are paid on a fee-for-service basis where demand cannot be met from normal working hours. There are a small number of GPs who operate a private practice only. They are paid on a fee-for-service basis on rates negotiated annual with Government.The National Corporation of Swedish Pharmacies run most pharmacies and negotiates the price of medicines with producers on an ongoing basis. This organization has been successful at containing the growth in the price of medicines when compared to other European countries, probably largely due to its purchasing power.ITALY:

41

Italy operates a National Health Service, which is available to all. Many health services attract a system of co-payments although GP services are freely available to all. Total expenditure is controlled by budgets allocated by central government although local authorities regularly exceed their budgets. Budgets are allocated primarily on the basis of system within an agreed time frame; the patient may opt to use selected private facilities at the expense of the national service. In 1989 primary care represented approximately 30% of total healthcare spending (source Instituto di Economica Sanitoria, 1992: Ministry of Health, 1989).The National Health Service is managed through a network of local authorities. Funding is provided by a combination of an insurance taxation on earnings and a contribution from general taxation. The insurance taxation is levied on both employers and employees and is income related. Tax relief is also available on private medical insurance premiums.Approximately 16% of the population have private medical insurance. Products provide cover principally for hospital services that complement the National Health Service.Co-payments apply on an ever-growing range of services, which includes diagnostic and laboratory tests, medicines and appliances. Most co-payments are per service, with a minimum and maximum amount applying. Low-income earners and the elderly are generally exempted from co-payments.GPs act as the gatekeepers to the hospital system. Most GPs are under contract to the National Health Service. While patients must register with a specific GP they are free to switch between GPs within their local authorities. GPS length of experience, the age of patients and his/here region. Additional allowances are also available e.g. practice allowances. A system of fee-for-service was introduced for a limited number of procedures but was subsequently withdrawn due to the higher than expected volumes. GP capitation rates are negotiated with Government on a regular basis.

42